Psychosis

Question 1

definition of psychosis

Answer 1

Qualitatively different from normal experience

Involve inability to distinguish between subjective experience and reality

Characterised by lack of insight

Question 2

Ddx of psychotic symptoms

Answer 2

Schizophrenia
Psychoactive Substance Use
Mania
Depression
Schizoaffective Disorder
Delirium
Dementia
Other organic cause

Question 3

what are self-referential experiences

Answer 3

The belief that external events are related to oneself

e.g. TV is transmitting messages to me

Question 4

what do you need be aware of in regards to drug induced psychosis

Answer 4

comorbidity of substance use and schizophrenia & bipolar disorder
- more likely to misuse illicit drugs more than the general population

Question 5

what does the presence of psychosis in depression show

Answer 5

severity of depression

i.e. very severe

Question 6

what psychotic Sx are seen in depression

Answer 6

Delusions of worthlessness / guilt / hypochondriasis / poverty

Hallucinations of accusing / insulting / threatening voices – typically 2nd person

Question 7

what are psychotic Sx in depression almost always

Answer 7

mood congruent content of psychotic Sx

Question 8

what psychotic Sx are seen in mania with psychosis

Answer 8

Delusions of grandeur / special ability / persecution / religiosity
Hallucinations: auditory (e.g. God’s voice)
Flight of ideas

Question 9

what is schizoaffective disorder

Answer 9

Schizophrenia + bipolar disorder

Question 10

what is characteristic of Schizoaffective disorder

Answer 10

presence of both Sx typical of schizophrenia and affect disorder
= episodes either schizo-manic or schizo-depressed

Question 11

what is delirium

Answer 11

Acute confusion with transient global disturbance

Question 12

what needs to be consider in delirium as well

Answer 12

alcohol withdrawal, infection, medical / surgical in-patients, septicaemia, organ failure. hypoglycaemia, post-op hypoxia, post-ictal, encephalitis, space occupying lesion, drug intoxication or withdrawal

Question 13

what are Sx of delirium

Answer 13

Clouding of consciousness

• ranges from subtle drowsiness to unresponsive
• disorientation in time, place & person
• fluctuating severity over time (lucid intervals)
• worse at night

impaired concentration/memory
- esp for new information

• visual hallucinations / illusions
± auditory hallucinations (often threatening)
• persecutory delusions
• psychomotor disturbance;
  agitation or retardation
• irritability
• insomnia

Question 14

what do dopamine receptor subtypes do (D1 and D2)

Answer 14

D1 receptor family (D1 & D5):
- stimulate cAMP

D2 receptor family (D2,D3,D4):

• inhibit Adenylyl Cyclase
• inhibit voltage-activated Ca2+ channels
• open K+ channels

Question 15

through what receptor family do typical (1st Gen) antipsychotics work

Answer 15

D2 inhibition

Question 16

why are atypical (2nd Gen) antipsychotics preferred

Answer 16

less likely to induce extra-pyramidal side effects

Better efficacy against negative symptoms

Effective in patients unresponsive to typical drugs

Question 17

what are extra-pyramidal side effects

Answer 17

acute dystonic reaction
parkinsonism
akathisia
dyskinesia

Question 18

how does acute dystonic reaction present

Answer 18

Usually painful
Usually distressing
Very easily treated with anticholinergics
Develops quickly

Question 19

what are features of parkinsonism caused by anti-psychotic

Answer 19

Drug-induced symptoms
Tremor
Rigidity
Festinating gait
If you need the drug and cant stop it, add in anticholinergic
Develops over a few days

Question 20

what are features of akathisia

Answer 20

Restlessness
Particularly in the legs
Need to move leg to get rid of the itch e.g.
Might find people to walk a lot, or walk on the spot
Constantly moving, uncomfortable if sit still
Difficult to treat, unless reduce antipsychotic
Develops over a few days

Question 21

what are features of dyskinesia

Answer 21

Abnormal involuntary movement
Typically oral or peri-oral i.e. Lips, tongue
Typically on the move

Not often recognized by the individual – usually other people the notice it

Very hard to treat, and once it is developed it continues to develop/get worse when you remove the antipsychotic

Slow, delayed
Doesn’t happen for year

Question 22

what is metabolic syndrome

Answer 22

abdominal (central) obesity 
elevated blood pressure
elevated fasting plasma glucose
high serum triglycerides
low HDL levels

Question 23

anti-psychotics block histamine receptors = what Sx does this cause

Answer 23

sedation

increased appetite

Question 24

anti-psychotics block alpha-adrenergic receptors = what Sx does this cause

Answer 24

postural hypotension

Question 25

what are the difference in side effects of atypical and typical anti-psychotics

Answer 25

typical - more motor

atypical - more metabolic

Question 26

blockade of what receptor causes extra pyramidal side effects and what other Sx do you get when this is affected

Answer 26

D2 blockade

Hyperprolactinaemia

Question 27

what should you do if a patient on clozapine has a sore throat

Answer 27

FBC

Question 28

how is clozapine monitored

Answer 28

Weekly for the first six months

Fortnightly for the next six months

Every four weeks thereafter

For one month after cessation of clozapine